Assessment Of Specimen Adequacy Research Articles

Top tips regarding EUS-guided liver biopsy

Top tips regarding EUS-guided liver biopsy

Allaying uncertainty in diagnosing buried Barrett's esophagus

Subsquamous intestinal metaplasia (SSIM) in the setting of Barrett's esophagus (BE) is a technically challenging diagnosis. While the risk for progression of BE involving the surface mucosa is well documented, the potential risk for development of advanced neoplasia associated with SSIM has been controversial. This study aimed to determine the effects of specimen adequacy, presence of dysplasia, and interobserver agreement for SSIM interpretation. Adult patients (n = 28) who underwent endoscopic therapy for BE with high-grade dysplasia or intramucosal carcinoma (HGD/IMC) between October 2005 and June 2013 were included. Initial evaluation (n = 140 slides) by an experienced gastrointestinal pathologist was followed by an interobserver study by 8 pathologists. Forty-seven (34%) slides had insufficient subsquamous tissue to assess for SSIM. SSIM was found in 19% of all slides and 29% of slides with sufficient subsquamous tissue. At least one slide had SSIM in 54% to 64% of patients. Subsquamous low grade dysplasia (LGD) was found in 4 (15%) slides with SSIM and subsquamous HGD/IMC was found in 5 (19%) slides with SSIM. At the patient level, 8 (53%) had no dysplasia, 4 (27%) had LGD and 3 (20%) had HGD/IMC. Overall agreement for SSIM by slide was 92% to 94% (κ = 0.73 to κ = 0.82, moderate to strong agreement), and by patient was 82% to 94% (κ = 0.65 to κ = 0.87, moderate to strong agreement). This study confirms the need for assessing specimen adequacy and assessing the prevalence of SSIM and is the first to assess interobserver agreement for SSIM and dysplasia within SSIM.

Role of cytotechnologists in rapid onsite adequacy assessment of cytology materials for diagnostic workup and specimen allocation for ancillary testing using a standardized protocol

Data on the performance of cytotechnologists in assessing specimen adequacy of needle core biopsies (NCB) is scant and their role in specimen triaging for ancillary studies have not been well established. We retrospectively analyzed rapid onsite evaluation (ROSE) performed exclusively by cytotechnologists on 248 NCB and fine-needle aspiration (FNA) specimens. Overall adequacy and accuracy rates were determined by comparing to final diagnosis. We also reviewed the process of specimen allocation for ancillary testing to determine whether specimens were appropriately triaged at the time of ROSE. Of the 248 cases, 222 (89.5%) were touch imprint and 26 (10.5%) were FNA smears. The overall adequacy rate was 73.4% (182 of 248). Concordance for "adequate" interpretation by ROSE with unequivocal malignant or benign diagnoses on final interpretation was 95.6%. The sensitivity, specificity, and accuracy of ROSE for a final "positive for malignancy" were 89.2% (95% CI 83.04% to 93.69%), 43.24% (95% CI 31.77% to 55.28%), and 73.87% (95% CI 67.57% to 55.28%), respectively. Cases with "positive for malignancy" on final diagnosis were "adequate" by ROSE in 89.1% (132 of 148) and "inadequate" in 10.8% (16 of 148), P < 0.0001. Ancillary tests were performed in 168 of 248 (67.7%); the majority were immunohistochemical stains for determining tumor subtype. Predictive biomarkers were performed successfully in 100% of metastatic breast cancers. Cytotechnologists performed at a high level of competency in providing ROSE and allocating specimens for ancillary testing, which were performed successfully in the majority of cases. Implementation of a standardized protocol for tissue management/prioritization is of paramount importance to maximize tissue preservation and minimize wastage.

A "Back Light System" for Identification of Sites for Endoscopic Ultrasound-Guided Fine-Needle Aspiration in Solid Pancreatic Masses: A Prospective, Randomized Study with a Crossover Design.

Background/AimsWe applied a back light system (BLS) with a magnifying glass to improve the ability to assess the adequacy of specimen sampling using endosonography. We conducted this study to evaluate the efficacy of the BLS in sampling of specimens by endoscopic ultrasound-guided fine needle aspiration of solid pancreatic masses. MethodsThis was a prospective, randomized, crossover, single-center clinical trial. An endosonographer evaluated adequacy on gross visual inspection and identified whitish specimen sampling sites with and without the BLS according to a randomization sequence in the first and second passes with a 25-G needle. On cytological evaluation, the presence of well-defined pancreatic ductal epithelium was evaluated by a cytopathologist who was blinded to any clinical information. ResultsA total of 80 consecutive patients were eligible during the study period. Adequacy was observed for 52 specimens (65%) with the BLS and 54 (68%) without the BLS (p=0.88). In assessment of specimen adequacy on gross examination, only fair agreement was observed both with and without BLS (kappa score 0.40 and 0.29, respectively). ConclusionsThe BLS did not influence the ability to identify specimen sampling sites or reliable assessment of specimen site adequacy using gross visual inspection.

Mo1279 YIELD OF THE 22G FRANSEEN TIP CORE BIOPSY NEEDLE INSTEAD OF A STANDARD EUS-FNA NEEDLE IN 125 SELECTED “DIFFICULT” EUS TISSUE SAMPLING CASES

The yield of EUS tissue sampling using a standard FNA needle for epithelial cancers is generally >90%. However, there are cases where standard FNA needles perform poorly (ex: SMTs, linitis, autoimmune pancreatitis, chronic pancreatitis, well-differentiated cancers, etc.). We hypothesized that selective use of the Franseen tip core biopsy needle might improve the diagnostic yield in these “difficult” cases. When the 22g Franseen tip needle became available at our institution, we began to selectively use it for the following indications: 1) failed previous EUS-FNA, 2) atypical mass (possible met, differentiate NET from adenoca, etc.), 3) suspected GIST, 4) suspected linitis, 5) suspected AIP, 6) indeterminate mass in chronic pancreatitis, 7) suspected lymphoma. EUS-guided biopsy was performed with no stylet and no suction, with a multi-pass fanning technique, by one of 2 experienced endosonographers. Samples were expressed into formalin using air. Additional passes were performed as needed, after visual assessment of specimen adequacy, without ROSE. Analysis was performed on intent to sample basis. Between 12/15/2016 and 11/10/2017, 615 lesions were sampled. 125 cases (20.3%) met our criteria for Franseen tip needle biopsy: 102 masses [56% pancreas, 20% GI wall, 17% retroperitoneal, 7% liver, 1% mediastinum] and 23 nodes [78% retroperitoneal, 22% mediastinal]), mean diameter 31±22mm [median 25mm], mean # passes 2.2±1.2 [range 1-5]. The prevalence of malignancy was 77%. Adequate samples for histological analysis were obtained in 115/125 (92%). In 5/10 (50%) inadequate samples, long term follow up showed true negatives. Sensitivity for malignancy was 91.7%, negative predictive value 78.4%. There were no immediate complications. In selected difficult EUS tissue sampling cases, the 22g Franseen tip needle: 1) Provides samples adequate for histological analysis in 92%, 2) The sensitivity for malignancy is 91.7%. These results were obtained without ROSE. The 22g Franseen tip needle is an excellent choice in cases where traditional EUS-FNA results are inadequate, and ROSE is not required.

Percutaneous liver biopsy: retrospective study of primary and secondary hepatic lymphoma in twenty-one patients

Hepatic lymphoma (HL) is categorized as primary and secondary hepatic lymphoma (PHL and SHL). This disorder can present as hepatic mass or mass-like lesion. Chemotherapy often is the first line treatment for patients with HL. Thus, an accurate pre-management histological diagnosis is essential to potentially improve clinical outcomes. The present study was to explore the prevalence of HL in ultrasound guided liver biopsies for hepatic mass or mass-like lesions, to investigate HL associated clinicopathological features, to raise the awareness of early recognition and proper diagnosis of this entity, and to assess specimen adequacy in needle core biopsy. Twenty-one cases of HL were enrolled. Clinical and pathological characteristics were evaluated, quality of biopsies was assessed and pertinent literature was reviewed. HL was diagnosed in 0.94% of 2242 liver biopsy cases with ambiguous clinical presentation, laboratory tests and image studies. There were two cases of PHL (0.09%), and nineteen cases of SHL (0.85%). Histopathologically, diffuse large B-cell lymphoma was the most common type, followed by B-cell lymphoma not otherwise specified, T-cell lymphoma, Hodgkin's lymphoma, and B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma. Additionally, three lymphocytic infiltration patterns were documented microscopically. The nodular infiltration was the most common type. HL is a rare entity and histopathology along with ancillary tests remains the only way to make the diagnosis. Clinicians' awareness of this entity and early liver biopsy are essential in patient management.

Effects of nodule characteristics on sampling number and duration of thyroid fine-needle aspiration biopsy: size does not matter, but cystic degeneration ratio does.

Background Ultrasound-guided fine needle aspiration biopsy (FNAB) of thyroid nodules, though the most accurate method to rule out malignancy, still has an inherent risk of yielding non-diagnostic specimens despite immediate assessment of specimen adequacy by an on-site cytopathologist. Purpose To evaluate the effects of nodule volume and extent of cystic degeneration on total biopsy time and number of aspirations required for obtaining an adequate specimen. Material and Methods A total of 510 patients underwent FNAB by a single radiologist accompanied by a cytopathologist who immediately assessed each sample for specimen adequacy. All sampled nodules were single and had one maximum diameter > 10 mm. Nodule volumes and cystic degeneration ratios were calculated prior to the intervention. Aspirations were repeated until the cytological material was deemed adequate by the cytopathologist; the number of aspirations and total biopsy time were then recorded. Results Nodule volumes did not have significant effect on neither number of aspirations necessary for achieving specimen adequacy ( P > 0.05) nor total biopsy time (r = -0.148 with P = 0.001). Predominantly cystic nodules, compared to predominantly solid nodules, required more sampling per nodule (4.58 ± 1.11 vs. 3.44 ± 1.19 aspirations, P = 0.001) and longer total biopsy time (16.40 ± 6.19 vs. 11.15 ± 6.18 min, P = 0.001). Conclusion Predominantly cystic nodules require allocation of more time for biopsy. To ensure specimen adequacy when immediate specimen evaluation by an on-site cytopathologist is not possible, four samples from predominantly solid nodules and five passes through predominantly cystic nodules are required.

Adequacy in voided urine cytology specimens: The role of volume and a repeat void upon predictive values for high-grade urothelial carcinoma.

Adequacy assessment is one of the most controversial and overlooked components in the daily practice of cytopathology, because it is generally determined from limited samples. Because voided urine varies widely in terms of its volume and cellularity, there is little consensus about the proper role for these variables in assessing specimen adequacy. In this study, the authors explored the role of volume in voided urine specimens to determine whether it plays a role in determining adequacy for the detection of high-grade urothelial carcinoma. Voided urine specimens received at the authors' laboratory over the 9.5 years since the introduction of the Johns Hopkins Template for Reporting Urinary Cytopathology were analyzed for correlations between volume, specimen adequacy, and the diagnosis of high-grade malignancy. The same data set also was queried to determine whether a patient who provided a voided low-volume specimen could yield a higher volume specimen and thereby increase adequacy. In total, 15,731 voided urine specimens with a cumulative volume of 891 liters originating from 8594 individual patients were analyzed. Specimen adequacy increased linearly for each increment of volume submitted to the laboratory up to 30 mL, after which the correlation was nonlinear. Low-volume specimens below this cutoff also had lower fractions of specimens that were diagnosed as malignant or suspicious. Volume is an important component in the evaluation of adequacy for voided urine cytology specimens.

The Value of Gross Visual Assessment of Specimen Adequacy for Liquid-Based Cytology During Ultrasound-Guided, Fine-Needle Aspiration of Thyroid Nodules

Major problems of fine-needle aspiration (FNA) of thyroid nodules arise due to nondiagnostic results caused by inadequately obtained FNA specimens. The purpose of this study was to evaluate the value of visual assessment of liquid-based cytology specimens during FNA of thyroid nodules for predicting sampling adequacy. For 3 months, visual assessment of FNA specimens was used for 534 consecutive nodules in 534 patients. The FNA specimens were visually graded immediately following aspiration for each nodule, and the visual grades were classified into 2 categories: inadequate (<6 cell groups) and adequate (>6 cell groups). The cytology results were classified as diagnostic or nondiagnostic based on the Bethesda system. We compared the ultrasound features and FNA characteristics between the diagnostic and nondiagnostic results. Multiple logistic regression analysis was used to determine factors independently predictive of nondiagnostic results. We also evaluated the interobserver agreement regarding the visual assessment. Visual assessment was feasible in all patients, and the nondiagnostic rate was 11.6% (62 of 534). Nondiagnostic results were more frequent in the inadequate visual assessment group (38.1%) than in the adequate visual assessment group (10.5%) (P = .001). Independent predictive factors for nondiagnostic results were inadequate visual assessment (odds ratio, 5.18), >50% vascularity (odds ratio, 3.98), and macrocalcification (odds ratio, 3.60). Interobserver agreement for the prediction of visual assessment was good (κ value, 0.767; P<.001). Immediate visual assessment of a specimen during FNA of a thyroid nodule is a feasible method for predicting sampling adequacy.

The accuracy of endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-GUIDED FNAB) cytology for the diagnosis of pancreatic malignancy at the wollongong hospital (TWH)

Aim To determine the accuracy of EUS-guided FNAB cytology for the diagnosis of pancreatic malignancy at TWH. Methods Retrospective study of all cases ( n = 53) of EUS-guided FNAB cytology of pancreatic lesions at TWH, from introduction of the procedure in February 2013 until September 2014. Patients with no histological or clinico-radiological diagnosis of malignancy and n = 13). Cytology findings ( n = 40) were compared to subsequent histological and clinico-radiological diagnoses. Results EUS-guided FNAB cytology demonstrated high accuracy in the diagnosis of pancreatic malignancy: sensitivity 88%; specificity 100%; positive predictive value (PPV) 100%; negative predictive value (NPV) 89%. The diagnostic yield was 92% (i.e., ‘non-diagnostic’ cytology = 8%; 3/40 cases). All cytological reports of ‘atypical cells’ and 67% of ‘non-diagnostic’ specimens were followed by a histological or clinico-radiological diagnosis of malignancy. Discussion Diagnostic yield, sensitivity, specificity, PPV and NPV were equivalent to figures published in other studies. 1–5 A patient who underwent the procedure without a cytotechnician present had ‘non-diagnostic’ cytology and was subsequently diagnosed with pancreatic adenocarcinoma. The authors recommend microscopic assessment of specimen adequacy during the procedure, which has been shown by other studies 2,6–8 to improve diagnostic yield, sensitivity and overall accuracy in the diagnosis of pancreatic malignancy.

Rapid on-site evaluation of fine needle aspiration specimens by cytology scientists: a review of 3032 specimens.

To determine: (1) the accuracy of cytology scientists at assessing specimen adequacy by rapid on-site evaluation (ROSE) at fine needle aspiration (FNA) cytology collections; and (2) whether thyroid FNA with ROSE has lower inadequacy rates than non-attended FNAs. The ROSE of adequacy for 3032 specimens from 17 anatomical sites collected over a 20-month period was compared with the final report assessment of adequacy. ROSE was performed by 19 cytology scientists. The report profile for 1545 thyroid nodules with ROSE was compared with that for 1536 consecutive non-ROSE thyroid FNAs reported by the same cytopathologists during the study period. ROSE was adequate in 75% (2276/3032), inadequate in 12% (366/3032) and in 13% (390/3032) no opinion was rendered. Of the 2276 cases assessed as adequate by ROSE, 2268 (99.6%) were finally reported as adequate for assessment; eight specimens had adequacy downgraded on the final report. Fifty eight per cent of cases with a ROSE assessment of inadequate were reported as adequate (212/366), whereas 93% (363/390) with no opinion rendered were reported as adequate. The overall final report adequacy rate for the 3032 specimens was 94% (2843/3032). Confirmation of a ROSE of adequacy at reporting was uniformly high amongst the 19 scientists, ranging from 98% to 100%. The inadequacy rate for thyroid FNAs with ROSE (6%) was significantly (P<0.0001) lower than for non-ROSE thyroid FNAs (17%). A significantly (P=0.02) higher proportion of adequate ROSE thyroid specimens was reported with abnormalities, compared with non-ROSE thyroid collections. Cytology scientists are highly accurate at determining specimen adequacy at ROSE for a wide range of body sites. ROSE of thyroid FNAs can significantly reduce inadequate reports.

Diagnostic Accuracy of EUS-FNA Without On-Site Cytopathology in a Community Hospital

Purpose: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a method for obtaining tissue diagnosis for masses found in the gastrointestinal (GI) tract. The use of on-site cytopathologist is usually used to assess specimen adequacy and diagnosis; but many centers do not have this service available in daily clinical practice. The goal of this study was to retrospectively evaluate the diagnostic yield of EUS-FNA in patients presenting with solid lesions of the GI tract in a practice setting with no on-site cytopathology. Methods: We retrospectively looked at all EUSs done at our institution with FNA done for masses from 1/1/09 to 12/31/12. Two endoscopists performed all the EUSs. There were no on-site cytopathologist for any of the procedures. We then correlated the pathology report with the EUS report. Adequate specimen collection rate, cytological diagnosis and number of needle passes were evaluated. Results: Over the three year period a total number of 438 total EUS were done. 118 EUS were done for solid masses (pancreas and stomach) of which 90 were biopsied (mean age 67.8; age range 43-93). 43% were male. Average number of passes was 3.5. There were adequate samples in 87 of the 90 (96.6%) specimens that were obtained. None of these patients developed complications from the procedure. Conclusion: Performing EUS-guided FNA for the cytological diagnosis of gastrointestinal masses without on-site cytopathology does not significantly increases the number of inadequate samples when compared to recent studies which showed 1% inadequate sample with the availability of on-site pathology.

Tu1561 The Performance of Pathology Trainees Compared to Non-Physician Cytotechnologists in the Assessment of EUS-FNA Specimen Adequacy

The Performance of Pathology Trainees Compared to NonPhysician Cytotechnologists in the Assessment of EUS-FNA Specimen Adequacy James L. Buxbaum*, Arthur W. Yan, Kavel H. Visrodia, Christianne J. Lane, Brett Quarto, Michael Y. Chan, Mehrdad Saliminejad Division of Gastrointestinal & Liver Diseases, Univ. of Southern California, Los Angeles, CA Background: The performance of rapid on-site evaluation (ROSE) of endoscopic ultrasound fine needle aspiration (EUS-FNA) samples by an attending cytopathologist to determine specimen adequacy has been shown to minimize additional procedures, optimize associated costs, and reduce complications. However, due to financial and manpower limitations, ROSE by an attending cytopathologists is not available at many centers and the realtime assessment of adequacy of EUS-FNA specimens is done by pathology trainees (resident or fellow) or cytotechnologists. The aim of this study is to compare the performance of pathology trainees and cytotechnologists in the determination of EUS-FNA specimen adequacy. Methods: A prospective database was developed in January 2010 following the establishment of two new academic ultrasound programs, one at Los Angeles County Hospital Medical Center (LAC), and the other at the USC Keck and Norris Hospitals (USC), a tertiary referral medical center. Among 365 consecutive patients, 221 anatomic targets were biopsied via EUS-FNA. EUS was performed at both centers by the same endosonographer and the same team of attending cytopathologists evaluated the samples after completion of the procedures. Real time adequacy of EUS-FNA samples at LAC was determined by pathology trainees, while at USC this was determined by non-physician cytotechnologists. The final assessment of the attending cytopathologist was the gold standard used to compare the performance of the trainees versus the cytotechnologists. Results: During the bedside evaluation all of the FNA samples were felt to be adequate at both institutions. However, final review of the samples by an attending pathologist determined that the adequacy of the specimens was 65.2% at LAC and 70.5% at USC (Table 1). There was no significant difference in the assessment of specimen adequacy by pathology trainees compared to experienced technologists (P 0.462). No difference in the performance of cytology trainees and the technicians was seen when the comparison was stratified by FNA target including pancreas masses, lymph nodes, or subepithelial lesions. Impression: These results suggest that there is no difference in the determination of diagnostic adequacy by a pathology trainee (resident or fellow) compared to an experienced non-physician cytology technician. Nonetheless, assessment of adequacy by both groups was suboptimal, which further underscores the need for an attending cytopathologist to determine the adequacy of EUS acquired fine needle aspirates in real-time. Other alternatives including telecytology, which allows for microscope images to be dynamically transmitted to a remotely located pathologist during EUS-FNA, are important considerations in health care systems where pathology resources are limited.

Best Practices in Endoscopic Ultrasound–Guided Fine-Needle Aspiration

Over the past 2 decades, endoscopic ultrasound-guided fine-needle aspiration has evolved to become an indispensable tool for tissue acquisition in patients with gastrointestinal tumors. The technique is useful for biopsy of mucosal and submucosal lesions in which prior endoscopic biopsies have been nondiagnostic; to sample peri-intestinal structures such as lymph nodes; and to sample masses in the pancreas, liver, adrenal glands, gallbladder, and bile duct. Also, with the advent of neoadjuvant therapies for diseases such as pancreatic cancer, most patients require a tissue diagnosis before initiating treatment. This review provides a perspective on technical issues that are key for best practices in endoscopic ultrasound-guided fine-needle aspiration.

Does cytotechnician training influence the accuracy of EUS-guided fine-needle aspiration of pancreatic masses?

Background/aimThe presence of on-site cytopathologists improves the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic masses; however, on-site cytopathologists are not available to all endoscopic units. We hypothesized that experienced cytotechnicians can accurately assess whether an on-site pancreatic mass fine needle aspiration specimen is adequate. The aim of this study was to evaluate the effect of formal cytotechnician training on the diagnostic accuracy of EUS-FNA of pancreatic masses. MethodsSingle-centre, prospective study. The cytotechnician made an on-site assessment of specimen adequacy with immediate evaluation of smears over a 12-month period (pre-training period) then over another 12-month period (post-training period), with a year's intermediate training when the cytopathologist and the cytotechnician worked together in the room. The gold standard used to establish the final diagnosis was based on a non-equivocal fine needle aspiration biopsy reviewed by the same expert cytopathologist. The main outcome measurements were the cytotechnician diagnostic accuracy before and after the training period. ResultsA total of 107 patients were enrolled in the pre-training period. Cytotechnician in-room adequacy was 68.2% (73/107). The diagnostic accuracy was 74.8%. The adequacy for the blind-review pathologist was 93.4% (100/107), significantly higher (p=0.008) than the cytotechnician's results. During the post-training period, 95 EUS-FNA were performed and reviewed. Cytotechnician in-room adequacy was 87.4% (83/95). The diagnostic accuracy was 90.5%. The adequacy for the blinded pathologist was 95.8% (91/95), not significantly different from the cytotechnician (p=0.23). ConclusionsAn adequate training period with an expert pathologist significantly improves the cytotechnician skill in terms of judging adequacy and diagnostic accuracy.

Retrospective evaluation of instituted standard adequacy criteria for on‐site adequacy assessment of thyroid fine‐needle aspiration

This retrospective study was conducted to investigate the impact of using instituted standard criteria for on-site assessment of specimen adequacy on fine-needle aspiration (FNA) diagnosis of thyroid nodules. The study included a total of 1,031 thyroid FNAs that were performed and assisted with on-site adequacy assessment using instituted standard criteria from July 2006 to March 2009. Adequate specimens require the presence of at least six groups of follicular cells in total on Diff-Quik stained smears with a minimum of 10 cells in each group. Agreement on specimen adequacy between on-site and final assessment, nondiagnostic rate, distribution of cytologic diagnoses, and cytohistologic concordance for cases with surgical follow-up was evaluated. Implementing the instituted standard criteria resulted in 93% level of agreement on specimen adequacy between on-site and final assessment. Nondiagnostic rate upon final assessment was 10.7%. Cytohistologic concordant rate reached 93.9% and 82.3% for nonneoplastic and neoplastic lesions, respectively. Most importantly, this approach to standardization not only provided diagnostic consistency among cytopathologists, but also minimized confusions and enhanced effective communication. Thus, high satisfactions have been achieved from endocrinologists/radiologists who utilized our on-site assessment service and/or participated in the management of thyroid nodules.

Sa1477 Translumenal Access for Endoscopic Pancreatic Necrosectomy: the Safe Entrance for Necrosectomy Sans Electrocautery (SENSE) Technique

Then each slide was processed to be stained at the department of cytopathology and reviewed by cytopathologists to assess the specimen adequacy. Results: Seventy-eight specimens were collected from 33 patients. Aspirated lesions were as follows: 46 pancreas (59.0%), 14 intra-abdominal lymph nodes (17.9%), other intra-abdominal organ (17.9%) and mediastinal lymph node (5.1%). Of these, malignancies were 69.2%, borderline malignancies 3.8% and benign lesions 26.9%. The positive predictive value (PPV) of non-bloody white core for prediction of specimen adequacy was 95.2% and the PPV of bloody core with white spots was 100.0%. Among adequate sample slides, non-bloody white core was observed in 60.6% and bloody core with white spots were observed only in 28.8%. Combined criteria of non-bloody white core and bloody core with white spots, presence of white core/spots showed sufficient value of sensitivity (89.4%), specificity (83.3%) and PPV (96.7%) for predicting sample adequacy. Conclusions: sVisual assessment of specimen adequacy seems to be very useful during EUS-FNA. Presence of white core/spots showed very high PPV. By using morphologic criteria with high PPV, it may be possible to reduce the number of needle pass and procedural time in general fields of practice. In future, studies for decreasing interobserver variability should be followed.

EchoBrush may be superior to standard EUS‐guided FNA in the evaluation of cystic lesions of the pancreas

Cystic lesions of the pancreas are being detected with increasing frequency. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is one of the most precise methods of diagnosis but still has limited accuracy. A new, through-the-needle cytologic brush system (EchoBrush; Cook Medical, Bloomington, Ind) has been approved for use during EUS evaluation of cystic pancreatic lesions. Data from 127 EUS-FNAs of pancreatic cystic lesions were analyzed to compare the cytologic yield of EchoBrush with conventional EUS-FNA. An attending cytopathologist was present on site to assess specimen adequacy in all the cases. Diagnostic yields of both procedures, as well as related adverse events, were recorded. Statistical analysis was performed with the SPSS 15.0 version software (SPSS, Chicago, Ill). A total of 127 cystic lesions of the pancreas from 120 patients (42 men and 78 women, mean age of 62.17 ± 12.17 years) were included in the study. Mean size of lesions was 23.58 ± 21.69 mm. Adequacy of the samples and diagnostic yield were higher using EchoBrush. In 80 (63 %) cases, conventional EUS-FNA was performed, whereas in 47 (37%), we used EchoBrush. Diagnostic material was obtained in 85.1% (40 of 47) of cases using EchoBrush and in 66.3% (53 of 80) with conventional EUS-FNA. (P < .05). There were very few clinically relevant complications related to EUS-FNA and EUS-EchoBrush techniques. This study suggests that cytological specimens from pancreatic cystic lesions obtained using EchoBrush at the time of EUS are superior to conventional EUS-FNA mainly because of the higher yield of epithelial cells. Larger studies are needed to compare both methods.

908 EVALUATION OF ADEQUACY OF PATHOLOGIC SPECIMENS USING A NOVEL BACKLOADING URETEROSCOPIC BIOPSY FORCEPS

You have accessJournal of UrologyTechnology & Instruments: Robotics/Laparoscopy/Ureteroscopy II1 Apr 2010908 EVALUATION OF ADEQUACY OF PATHOLOGIC SPECIMENS USING A NOVEL BACKLOADING URETEROSCOPIC BIOPSY FORCEPS Shaun Wason, Alan Schned, John Seigne, and Vernon Pais Shaun WasonShaun Wason More articles by this author , Alan SchnedAlan Schned More articles by this author , John SeigneJohn Seigne More articles by this author , and Vernon PaisVernon Pais More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1664AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Quality of ureteroscopic biopsies may be limited by the small specimen size. Dictated by the working channel of the ureteroscope, biopsy forceps of 3fr have less than 1mm3 of biopsy head volume. Utilizing a backloading design, the BIGopsy™ ureteroscopic biopsy forceps has a biopsy head larger than the working channel of the ureteroscope. Recognizing that small biopsied tissue volume may preclude adequate pathologic evaluation, we sought to assess the adequacy of surgical specimens obtained utilizing the BIGopsy™ forceps. METHODS In accordance with our IRB, patients undergoing nephroureterectomy for suspected upper tract TCC were recruited. Surgical specimens, immediately after extirpation were examined. The most clinically suspicious region to gross examination was alternatively biopsied with a 3fr Piranha® followed by the BIGopsy™ biopsy forceps. These specimens were fixed, stained and evaluated by a single pathologist. Biopsy size and qualitative assessment of specimen adequacy were recorded. Pathologic diagnosis of the biopsy specimens were compared to the final pathologic diagnosis. RESULTS Three nephroureterectomy specimens were evaluated. A total of 6 biopsies were obtained from the Piranha® and 5 biopsies from the BIGopsy™. Biopsy size from the Piranha® ranged from 1 to 8mm2, while those from the BIGopsy™ ranged from 6 to 80mm2. Average biopsy size from the Piranha® was 3.5 +/- 2.8mm2 while the average biopsy size from the BIGopsy™ was 31.2 +/-34.6mm2. In 2 of 3 nephroureterectomy specimens, final diagnosis was high grade papillary urothelial carcinoma in accordance with both the Piranha® and BIGopsy™ specimens. In the third specimen, the final diagnosis was benign polypoid/papillary pyelitis consistent with only the BIGopsy™ specimen, while the Piranha® specimen was suspicious for a low grade papillary lesion. Subjectively, the BIGopsy™ specimens revealed less distortion and fragmentation and were easier to interpret by the pathologist. Smooth muscle was contained in 1 of 3 BIGopsy™ specimens and in none of the Piranha® specimens. CONCLUSIONS The BIGopsy™ backloading biopsy forceps allows removal of ureteral and renal pelvic tissue larger than the standard 3fr biopsy forceps. In all 3 cases, the diagnosis based upon the BIGopsy™ biopsy agreed with the final pathologic report, one of which was pathologically misassigned as malignant by the smaller 3fr Piranha® biopsy forceps specimen. Improved biopsy quality may translate into improved ability to diagnose ureteral and renal pelvic mucosal lesions endoscopically. Lebanon, NH© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e354-e355 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shaun Wason More articles by this author Alan Schned More articles by this author John Seigne More articles by this author Vernon Pais More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A real‐time PCR assay to identify and discriminate among wild‐type and vaccine strains of varicella‐zoster virus and herpes simplex virus in clinical specimens, and comparison with the clinical diagnoses

A real-time PCR assay was developed to identify varicella-zoster virus (VZV) and herpes simplex virus (HSV) DNA in clinical specimens from subjects with suspected herpes zoster (HZ; shingles). Three sets of primers and probes were used in separate PCR reactions to detect and discriminate among wild-type VZV (VZV-WT), Oka vaccine strain VZV (VZV-Oka), and HSV DNA, and the reaction for each virus DNA was multiplexed with primers and probe specific for the human beta-globin gene to assess specimen adequacy. Discrimination of all VZV-WT strains, including Japanese isolates and the Oka parent strain, from VZV-Oka was based upon a single nucleotide polymorphism at position 106262 in ORF 62, resulting in preferential amplification by the homologous primer pair. The assay was highly sensitive and specific for the target virus DNA, and no cross-reactions were detected with any other infectious agent. With the PCR assay as the gold standard, the sensitivity of virus culture was 53% for VZV and 77% for HSV. There was 92% agreement between the clinical diagnosis of HZ by the Clinical Evaluation Committee and the PCR assay results.